In a small room stuffed with cubicles at Mercy Medical Center in Des Moines, a team of patient advocates answers phones, enters data, and determines who is eligible for financial assistance.

When a patient at Mercy is faced with a hospital bill they can’t pay, they come here. Team leader Karla Vaquerano-Serio says many times, it’s only a matter of helping a patient sign up for a federal program they didn’t realize they qualified for.

“I have patients, who have a $30,000 bill and get on Medicaid to get it covered… and I’ve run into them at places and they give me a huge hug because they’re so grateful,” Vaquerano-Serio said.

When it comes to medical billing, everyone pays a different price. Insurance companies negotiate rates far below what hospitals initially charge. Medicare sets its own rates, and that can leave people who don’t have insurance paying the highest price.

Vaquerano-Serio’s eight-person team works with nearly a thousand uninsured patients a month.

“We have patients that come in, they were in a car accident or something like that and weren’t expecting a medical bill and they’re here at the hospital,” she says. “We see families whose insurance has lapsed because they didn’t pay a premium, or were on state-funded insurance and didn’t renew their application.”

For someone without insurance, an emergency room bill can be financially devastating. Mercy carves out funding for some ‘charity care.’ In the last fiscal year, it totaled $6,897,000.

Joe LeValley is the senior vice president of planning and advocacy for the hospital. He says seven years ago, the Board of Directors voted to begin the advocacy program, expand charity care, and offer a 62% discount to all patients who were paying medical bills out of their own pocket.

“The uninsured would get the same rate as the major insurance companies. Your bill is adjusted down by 62 percent because that’s what the insurance companies get on average, as a discount,” LeValley said.

UnityPoint and the University of Iowa Hospitals also offer discounts to uninsured patients, ranging from 20-25% off… but only if you call to request it.

But why do insurance companies get the better deal? Cliff Gold is the Chief Financial Officer for West Des Moines-based Co-Opportunity Health, one of the nonprofit insurance co-ops given startup loans by the Affordable Care Act. Gold says hospital charges—collected on a document called a ‘chargemaster’—are kind of like the sticker price on a car.

“That sticker price is nothing more than a starting point for negotiating,” Gold said. “If you’re an individual buyer of a car, you don’t have a lot of negotiating space. If you’re a fleet buyer of cars… and you’re going to buy from the manufacturer thousands of cars, your negotiating position is much better.”

That means insurers with the highest market share hold the most sway—in Iowa, Wellmark is the dominant force. Gold says that because it’s a hospital’s largest customer, it usually gets the lowest price.

“It’s more an implicit understanding that they won’t give a better price to anybody else. That doesn’t mean they don’t do it,” Gold said.

But Gold says he’s hopeful his co-op will improve the competitiveness of Iowa’s insurance market…reducing premiums, and giving people who weren’t insured before a chance to get coverage.